Provider Demographics
NPI:1457494163
Name:HEINE, KEMBER B (DMD)
Entity type:Individual
Prefix:DR
First Name:KEMBER
Middle Name:B
Last Name:HEINE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 349
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:KY
Mailing Address - Zip Code:42459
Mailing Address - Country:US
Mailing Address - Phone:270-333-4030
Mailing Address - Fax:207-333-7998
Practice Address - Street 1:1107 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:KY
Practice Address - Zip Code:42459
Practice Address - Country:US
Practice Address - Phone:270-333-4030
Practice Address - Fax:270-333-7998
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY67211223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60067212Medicaid